postpci围手术期抗血小板策略项美香.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,post-PCI围手术期抗血小板策略,浙江大学医学院附属第二医院,心内科 项美香,ACC/AHA/SCAI Focused Update of the Guideline for Percutaneous Coronary Intervention2007 Writing Committee Members,Spencer B.King III,MD,MACC,FAHA,FSCAI,Co-Chair,Sidney C.Smith,MD,FACC,FAHA,Co-Chair,John W.Hirshfeld,Jr,MD,FACC,FAHA,FSCAI,Alice K.Jacobs,MD,FACC,FAHA,FSCAI,Douglass A.Morrison,MD,PhD,FACC,FSCAI,David O.Williams,MD,FACC,FAHA,FSCAI,Antiplatelet Therapy,A loading dose of clopidogrel,generally 600 mg,should be administered before or when PCI is performed.,Modified recommendation,In patients undergoing PCI within 12 to 24 hours of receiving fibrinolytic therapy,a clopidogrel oral loading dose of 300mg may be considered.,Modified recommendation,For all post-PCI stented patients receiving a DES,clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.,Modified recommendation,For patients receiving BMS,clopidogrel should be given for a minimum of 1 month and ideally up to 12 months(unless at increased risk of bleeding).,Modified recommendation,Antiplatelet Therapy,If clopidogrel is given at the time of procedure,supplementation with GP IIb/IIIa receptor antagonists can be beneficial.,Modified,For patients with an absolute contraindication to aspirin,it is reasonable to give a 300 mg to 600 mg loading dose of clopidogrel,administered at least 6 hours before PCI,and/or GP IIa/IIIa antagonists at the time of PCI.,No Change,In patients with increased risk of bleeding,a lower dose of 75 mg to 162 mg of aspirin is reasonable during the initial period after stent implantation.,New,Continuation of clopidogrel therapy beyond 1 year may be considered in patients undergoing DES placement.,New,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,B,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,Antiplatelet Therapy,Patients already taking daily long-term aspirin should,take 75 mg to 325 mg before PCI.,No changes,Patients not already taking daily aspirin should be given,300 mg to 325 mg of aspirin at least 2 hours and,preferably 24 hours before PCI.,No change,After PCI,in patients without allergy or increased risk of,bleeding,aspirin 162 mg to 325 mg daily should be given,for at least:,1 month after BMS,3 months after sirolimus-eluting stent,6 months after paclitaxel-eluting stent,Modified recommendation,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,Aspirin,No trials compared lower dose(75-162mg)with higher dose aspirin(162-325mg)as the initial course of therapy after DES in subacute or late stent thrombosis,The recommendation according to the clinical trial protocol,Higher dose aspirin increase the risk of bleeding,In the patients at high risk of bleeding,the use of low dose of aspirin.,Aspirin,Major bleeding events were more frequently in patients of taking SA 200mg+clopidogrel 75mg than that of taking ASA 100mg+clopidogrel 75mg,Antiplatelet effects could not be increased in higher dose of ASA,Clopidogrel,For all post-PCI patients who receive a DES,clopidogrel 75 mg daily should be given for at least 12 months if not at high risk of bleeding.,For post-PCI patients receiving as BMS,it should be given for a minimum of 1 month and ideally up to 12 months(unless patient is at increased risk of bleeding then it should be given for a minimum of 2 weeks).,Modified recommendation,For all post-PCI non-stented STEMI patients,treatment with clopidogrel should continue for 14 days.,New recommendation,Long-term maintenance therapy(e.g.1 year)with clopidogrel is reasonable in STEMI and NSTEMI who undergo PCI without reperfusion therapy.,New recommendation,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,I,I,I,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,IIa,IIa,IIa,IIb,IIb,IIb,III,III,III,Perioperative period,Under urgent situation,the duration studied for FDA approval,3 months for SES,6 months for PES,Predictors of late stent thrombosis,Small vessels,Multiple lesions,Long stents,Overlapping stents,Ostial or bifurcation lesions,Suboptimal stent result,Low EF,Advanced age,DM,Renal failure,ASC,Perioperative period,Elective surgery:postponed for 1 year,Not be deferred surgery,aspirin therapy considered in high risk patients with DES,Surgery with low risk of bleeding,continue DAT,谢谢,